Contributors The study was conceived by CV, SB and BDF. BDF was the principal investigator for the study and led the research into the
reliability of prescribing. SB is the main author of this paper and guarantor and led the research into the availability of
clinical information in outpatient clinics. KM led the research into equipment availability in theatres. MC led the research
into the availability of equipment to insert intravenous lines. CV was on the steering group for the study and helped with
design, interpretation of the findings and report writing. All authors contributed to methodological design, data analysis,
the synthesis of the overall study findings reported here and writing this paper. All authors have seen and approved the final
paper. Dr AV, Mr VD and Dr ES assisted with data collection and analysis. Dr MAS was part of the research team and helped
write the final report for the funders. Professor AH provided advice for the intravenous lines study. DE, a health economist
from York University, advised on the economic aspects of the findings.

Accepted 24 February 2012

Published Online First 11 April 2012

Abstract

Background It is well known that many healthcare systems have poor reliability; however, the size and pervasiveness of this problem
and its impact has not been systematically established in the UK. The authors studied four clinical systems: clinical information
in surgical outpatient clinics, prescribing for hospital inpatients, equipment in theatres, and insertion of peripheral intravenous
lines. The aim was to describe the nature, extent and variation in reliability of these four systems in a sample of UK hospitals,
and to explore the reasons for poor reliability.

Methods Seven UK hospital organisations were involved; each system was studied in three of these. The authors took delivery of the
systems' intended outputs to be a proxy for the reliability of the system as a whole. For example, for clinical information,
100% reliability was defined as all patients having an agreed list of clinical information available when needed during their
appointment. Systems factors were explored using semi-structured interviews with key informants. Common themes across the
systems were identified.

Results Overall reliability was found to be between 81% and 87% for the systems studied, with significant variation between organisations
for some systems: clinical information in outpatient clinics ranged from 73% to 96%; prescribing for hospital inpatients 82–88%;
equipment availability in theatres 63–88%; and availability of equipment for insertion of peripheral intravenous lines 80–88%.
One in five reliability failures were associated with perceived threats to patient safety. Common factors causing poor reliability
included lack of feedback, lack of standardisation, and issues such as access to information out of working hours.

Conclusions Reported reliability was low for the four systems studied, with some common factors behind each. However, this hides significant
variation between organisations for some processes, suggesting that some organisations have managed to create more reliable
systems. Standardisation of processes would be expected to have significant benefit.

Footnotes

Funding The study was commissioned and funded by the Health Foundation (Registered Charity Number 286967) as part of their work to
examine systems reliability in healthcare and its effects on patient safety. The Centre for Patient Safety and Service Quality
is supported by the UK National Institute of Health Research. The researchers are independent from the funders.

Competing interests All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) all authors have support from The Health Foundation
for the submitted work; (2) all authors have no relationships with The Health Foundation that might have an interest in the
submitted work in the previous 3 years; (3) their spouses, partners, or children have no financial relationships that may
be relevant to the submitted work; and (4) none of the authors have non-financial interests that may be relevant to the submitted
work.